54 Chapter 3 gender as a determinant associated with more inappropriate antibiotic prescribing in our framework (26,29,30). Two studies found an association between larger practice size and inappropriate antibiotic prescription while a third study found no association with practice size (29,31,35). A higher daily patient load was associated with more inappropriate prescription of antibiotics in one study (34). As practice size and patient load are generally related, a larger practice was included in the framework. The determinant age of the patient was investigated by seven studies (24–27,29,30,37). Two studies found that an age between 18 and 65 years was associated with increased inappropriate antibiotic prescription (26,29), one study concluded increasing age to be associated with greater inappropriate antibiotic prescription (37) and two studies failed to find any such association (24,27). Two studies focusing on otitis media found inappropriate antibiotic prescription more commonly occurred with children younger than 2 years of age as compared with children 2 years and older (25,30).This was therefore included in the framework as a determinant with conflicting results. The healthcare payment model was researched in several studies exploring various determinants, with some finding an association with inappropriate antibiotic prescription (32–35). An explorative study in Ireland from O’Doherty et al. reported a higher rate of inappropriate antibiotic prescriptions in self-paying or fee-for-service insured patients versus patients with free access to healthcare (33). Likewise, a study in Canada found fee-for-service providers more commonly inappropriately prescribed antibiotics than salaried providers (35). Another study from Canada failed to detect this association (34) and likewise found no association between inappropriate antibiotic prescription and a healthcare capitation payment system. Protecting business was singled out as a reason for inappropriate antibiotic prescription in a cross-sectional survey study in Australia (32). Framework determinants of inappropriate antibiotic prescribing As our aim was to construct a comprehensive framework as possible. The determinants practice location (rural vs urban), hospital affiliation and medical education outside the USA and Canada were put in the framework despite being specific to a country or setting (29,31,34,35). Rural locations in Canada have a different context than rural locations in Europe and this determinant should be used in that context (29). One study found that physicians trained outside Canada or USA prescribed more inappropriate antibiotics while working in Canada (31). The constructed framework provides a
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